Appendix Rational Use of FIGO Guidelines in Clinical Practice. Handbook CTG

Appendix

Rational Use of FIGO Guidelines in Clinical

Practice

The International Federation of Gynecology and Obstetrics (FIGO) released its revised

guidelines on CTG in October 2015 in collaboration with 37 member societies and with

a consensus panel comprising of 50 CTG experts around the world.

Table A1 CTG Classification Criteria, Interpretation and Recommended Management

Normal Suspicious Pathological

Baseline 110–160 Lacking at

astonecharacteristic

ofnormality, but with

nopathological

features

<100 bpm

Variability 5–25 Reduced variability for > 50

min, increased variability for

>30 min, or sinusoidal pattern

for > 30 min

Decelerations No repetitive*

decelerations

Repetitive* late or prolonged

decelerations during >30 min

or 20 min if reduced

variability, or one prolonged

deceleration >5 min

Interpretation Fetus with no

hypoxia/acidosis

Fetus with a low

probability of having

hypoxia/acidosis

Fetus with a high probability

of having hypoxia/acidosis

Clinical

management

No intervention

necessary to

imp

rove fetal

oxygenation

state

Action to correct

reversible causes if

identified, close

monitoring or

additional methods

to evaluate fetal

Immediate action to correct

reversible causes, additional

methods to evaluate fetal

oxygenation (Chapter 4), or if

this is not posible, expedite

delivery; in acute situationsoxygenation (cord prolapse, uterine rupture

or placental abruption),

imm

ediate delivery should be

accomplished

The presence of accelerations denotes a fetus that does not have hypoxia/acidosis, but their

absence during labour is of uncertain significance.

* Decelerations are repetitive in nature when they are associated with >50 percent of

uterine contractions.

Clinical Decision

Several factors, including gestational age and medication administered to the mother,

can affect FHR features, so CTG analysis needs to be integrated with other clinical

information for a comprehensive interpretation and adequate management. As a general

rule, if the fetus continues to maintain a stable baseline and a reassuring variability, the

risk of hypoxia to the central organs is very unlikely. However, the general principles

that should guide clinical management are outlined in the table.

FIGO guidelines clearly state that when fetal hypoxia/acidosis is anticipated or

suspected (suspicious and pathological tracings) and action is required to avoid adverse

neonatal outcome, this does not necessarily mean an immediate caesarean section or

instrumental vaginal delivery. The underlying cause for the appearance of the pattern can

frequently be identified and the situation reversed with subsequent recovery of adequate

fetal oxygenation and return to a normal tracing.

Good clinical judgement is required to diagnose the underlying cause for a

suspicious or pathological CTG to judge the reversibility of the conditions with which it

is associated and to determine the timing of delivery with the objective of avoiding

prolonged fetal hypoxia/acidosis as well as unnecessary obstetric intervention.

Additional methods may be used to evaluate fetal oxygenation. When a suspicious or

worsening CTG pattern is identified, the underlying cause should be addressed before a

pathological tracing develops. If the situation does not revert and the pattern continues to

deteriorate, consideration needs to be given for further evaluation or rapid delivery if a

pathological pattern ensues.During the second stage of labour, due to the additional effect of maternal pushing,

hypoxia/acidosis may develop more rapidly. Therefore, urgent action should be

undertaken to relieve the situation, including discontinuation of maternal pushing, and if

there is no improvement, delivery should be expedited

Implementation of FIGO Guidelines in Clinical

Practice

It is important that midwives and obstetricians employ the principles of fetal physiology

and physiological response to intrapartum hypoxic stress prior to taking action after

classifying the CTG trace as normal, suspicious or pathological. Baseline FHR should

be considered in accordance with the gestational age of the fetus (i.e. a postterm fetus

would be expected to have a lower baseline heart rate), as well as a rise in baseline

heart rate due to catecholamine surge may need action, even though the upper limit of the

threshold (i.e. 160 bpm) is not breached. It is important to determine the presence of

cycling and types of hypoxia while interpreting CTG traces.

Even if the CTG is classified as pathological, in the presence of a stable baseline

FHR and reassuring variability, usually no operative intervention is required other than

careful observation and/or alleviation of the cause of hypoxic or mechanical stress.

Conversely, a fetus with a ‘normal CTG’ may require an operative intervention (e.g.

clinical chorioamnionitis with failure to progress in labour). The presence of meconium

staining of amniotic fluid and ongoing clinical chorioamnionitis may result in

neurological injury secondary to meconium aspiration syndrome and inflammatory brain

damage, even if the CTG trace is not ‘pathological’. The use of tocolytics may help

improve utero-placental circulation if acute accidents such as placental abruption or

uterine rupture are excluded.

ObGyncases (Healthcare Touch)

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Appendix Rational Use of FIGO Guidelines in Clinical Practice. Handbook CTG

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